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Stroke

Topic Overview

What is a stroke?

A stroke occurs when a blood
vessel in the brain is
blocked or bursts. Without blood and the oxygen it carries, part of the brain
starts to die. The part of the body controlled by the damaged area of the brain
can't work properly.

Brain damage can begin within minutes. That's why it's so important to know the symptoms of stroke and to act fast. Quick treatment can
help limit damage to the brain and increase the chance of a full
recovery.

What are the symptoms?

Symptoms of a stroke happen
quickly. A stroke may cause:

Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.

Sudden vision changes.

Sudden trouble speaking.

Sudden confusion or trouble understanding simple statements.

Sudden problems with walking or balance.

A sudden, severe headache that is
different from past headaches.

If you have any of these symptoms, call 911 or other emergency services right away.

FAST is a simple way to remember the main symptoms of stroke. Recognizing these symptoms helps you know when to call for medical help. FAST stands for:

Face drooping.

Arm weakness.

Speech difficulty.

Time to call 911.

See your doctor if you have
symptoms that seem like a stroke, even if they go away quickly. You may have
had a
transient ischemic attack (TIA), sometimes called a
mini-stroke. A TIA is a warning that a stroke may happen soon. Getting early
treatment for a TIA can help prevent a stroke.

What causes a stroke?

There are two types of
stroke:

An
ischemic (say
"iss-KEE-mick") stroke happens when a blood clot blocks a
blood vessel in the brain. The clot may form in the blood vessel or travel from
somewhere else in the blood system. About 8 out of 10 strokes are ischemic strokes. They are the most common type of stroke in older
adults.

A
hemorrhagic (say "heh-muh-RAW-jick") stroke develops when an artery in the
brain leaks or bursts. This causes bleeding inside the brain or near the
surface of the brain. Hemorrhagic strokes are less
common but more deadly than ischemic strokes.

How is a stroke diagnosed?

You need to see a doctor right away. If a stroke is diagnosed quickly—right after symptoms start—doctors may be able to use medicines that can help you recover better.

The first thing the doctor needs to find out
is what kind of stroke it is: ischemic or hemorrhagic. This is important,
because the medicine given to treat a stroke caused by a blood clot could be
deadly if used for a stroke caused by bleeding in the brain.

To
find out what kind of stroke it is, the doctor will do a type of X-ray called a
CT scan of the brain, which can show if there is
bleeding. The doctor may order other tests to find the location of the clot or
bleeding, check for the amount of brain damage, and check for other conditions
that can cause symptoms similar to a stroke.

How is it treated?

For an ischemic stroke, treatment focuses on restoring blood flow to
the brain. You may be given a clot-dissolving medicine called
tissue plasminogen activator (t-PA). This medicine can improve recovery from a stroke, especially if given as soon as possible after the
stroke happens. Doctors try to give this medicine within 3 hours after symptoms start. Some people may be helped if they are able to get this medicine within 4½ hours of their first symptoms.footnote 1 Other medicines may be
given to prevent blood clots and control symptoms. A procedure may be done to remove the blood clot and restore blood flow.

For a
hemorrhagic stroke, treatment focuses on stopping the bleeding in the brain. Doctors may give you medicine or a transfusion with parts of blood, such as plasma. They may do
surgery to drain the blood or to reduce pressure on the brain.
Medicines may be used to control blood pressure, brain swelling, and other
problems.

After either kind of stroke and after your condition is stable, treatment shifts to
preventing other problems and future strokes. You may need to take a number of
medicines to control conditions that put you at risk for stroke, such as high
blood pressure or atrial fibrillation. Some people need to have a
surgery to remove
plaque buildup from the blood vessels that supply the
brain (carotid arteries).

The best way to get
better after a stroke is to start
stroke rehabilitation (rehab). The goal of stroke rehab is to help you
regain skills you lost or to make the most of your remaining abilities. Stroke
rehab can also help you take steps to prevent future strokes. You have the
greatest chance of regaining abilities during the first few months after a
stroke. So it is important to start rehab soon after a stroke and do a little
every day.

How can you prevent another stroke?

After you have had a
stroke, you are at risk for having another one. But you can make some important
lifestyle changes that can reduce your risk of stroke and improve your overall
health.

Treat any health problems you have

Manage high blood pressure or high cholesterol by working with your doctor.

Manage diabetes. Keep your blood sugar levels within a target range.

If your doctor recommends taking aspirin or a blood thinner, take it.

Take your medicine exactly as prescribed. Call your doctor if you think you are having a problem with your medicine.

Get the flu vaccine every year.

Adopt a healthy lifestyle

Don't smoke or allow others to smoke around you.

Limit alcohol to 2 drinks a day for men and 1 drink a day for women.

Stay at a healthy weight. Being overweight makes it more likely you will develop high blood pressure, heart problems, and diabetes. These conditions make a stroke more likely.

Do activities that raise your heart rate. Get at least 30 minutes of exercise on most days of the week. Walking is a good choice. You also may want to do other activities, such as running, swimming, cycling, or playing tennis or team sports.

Eat heart-healthy foods. These include fruits, vegetables, high-fiber foods, fish, and foods that are low in sodium, saturated fat, and trans fat.

Low blood pressure may also cause an
ischemic stroke, although this is less common. Low blood pressure results in reduced
blood flow to the brain. It may be caused by narrowed or diseased
arteries, a heart attack, a large loss of blood, or a severe infection.

Some surgeries (such as endarterectomy) or other procedures (such as
carotid artery stenting) that are used to treat narrowed carotid arteries may cause a blood
clot to break loose, resulting in a stroke.

Causes of hemorrhagic stroke

A
hemorrhagic stroke is caused by bleeding in or around the
brain.

Bleeding inside the brain itself (intracerebral hemorrhage, or ICH) may be a
result of long-term high blood pressure or use of blood thinner medicine, such as anticoagulants.

Bleeding in the space around the
brain (subarachnoid hemorrhage, or SAH) may be caused by a ruptured
aneurysm or uncontrolled high blood pressure.

Other less common causes include head or neck injuries, certain diseases, and radiation treatment for cancer in the neck or brain.

Symptoms

If you have symptoms of a stroke,
call 911 or other emergency services right away. General symptoms of a
stroke include:

Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.

Sudden vision changes.

Sudden trouble speaking.

Sudden confusion or trouble understanding simple statements.

Sudden problems with walking or balance.

A sudden, severe headache that is
different from past headaches.

FAST is a simple way to remember the main symptoms of stroke. Recognizing these symptoms helps you know when to call for medical help. FAST stands for:

Face drooping.

Arm weakness.

Speech difficulty.

Time to call 911.

Symptoms can vary depending on whether the stroke is caused by
a blood clot (ischemic stroke) or bleeding (hemorrhagic stroke), where the stroke occurs in the brain, and how bad it is.

A stroke usually happens suddenly but may occur over hours. For example, you may have mild weakness at first. Over time, you may not be able to move the arm and leg on one side of your body.

If several smaller strokes occur over time, you may
have a more gradual change in walking, balance, thinking, or behavior. This is called multi-infarct dementia.

It isn't always easy for people to recognize symptoms of a
small stroke. They may mistakenly think the symptoms can be attributed to
aging. Or the symptoms may be confused with those of other conditions that
cause similar symptoms.

What Happens

When you have an
ischemic stroke, the oxygen-rich blood supply to part of your brain is reduced.
With a
hemorrhagic stroke, there is bleeding in the
brain.

After about 4 minutes without blood and oxygen,
brain cells become damaged and may die. The body tries to restore
blood and oxygen to the cells by enlarging other blood vessels (arteries) near
the area.

This loss of function may be mild or
severe. It may be temporary or permanent. It depends on where and how much of the
brain is damaged and how fast the blood supply can be returned to the affected
cells. Life-threatening complications may also occur. This is why it's important to get treatment as soon as possible.

Recovery

Recovery
depends on the location and amount of brain damage caused by the stroke, the
ability of other healthy areas of the brain to take over for the
damaged areas, and
rehabilitation. In general, the less damage there is
to the brain tissue, the less disability results and the greater the chances of
a successful recovery.

Stroke is the most common nervous-system–related cause of physical
disability. Of people who survive a stroke, half will
still have some disability 6 months after the stroke.

You have the greatest chance of regaining
your abilities during the first few months after a stroke. Regaining some
abilities, such as speech, comes slowly, if at all. About half of all people
who have a stroke will have some long-term problems with talking,
understanding, and decision-making. They also may have changes in behavior that
affect their relationships with family and friends.

Race. African Americans, Native Americans, and Alaskan Natives
have a higher risk than those of other races.

Gender. Women have a higher risk of having a stroke compared to men. In people ages 55 to 75, about 2 out of 10 women will have a stroke and 1 or 2 out of 10 men will have a stroke.

Family history. The risk for stroke is greater if
a parent, brother, or sister has had a stroke or
transient ischemic attack (TIA).

History
of stroke or TIA.

When To Call a Doctor

Call 911 or other emergency services now if you have signs of a stroke:

Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.

Sudden vision changes.

Sudden trouble speaking.

Sudden confusion or trouble understanding simple statements.

Sudden problems with walking or balance.

A sudden, severe headache that is
different from past headaches.

Signs of a transient ischemic attack (TIA) are similar to signs of a stroke. But TIA symptoms usually disappear after 10 to 20 minutes, although they may last longer. There is no way to tell whether the symptoms are caused by a stroke or by TIA, so emergency medical care is needed for both conditions.

Call your doctor right away if you:

Have had recent symptoms of a TIA or stroke, even if
the symptoms have disappeared.

Are taking
aspirin or other medicines that prevent blood clotting and you notice any
signs of bleeding.

Have a
choking episode from food going down your windpipe.

Have signs of a blood clot in a
deep blood vessel, which include redness, warmth, and
pain in a specific area of your arm or leg.

Call your doctor for an appointment if you:

Think you have had a TIA in the past and have
not talked with your doctor about it.

Some hospitals have a stroke team made up of many
different health professionals, such as a neurologist, a neuroradiologist, a physical therapist, an occupational
therapist, a speech therapist, a rehabilitation doctor (physiatrist), a nurse,
and a social worker.

Exams and Tests

Tests in the emergency room

The first test after a stroke is
typically a
CT scan, a
series of X-rays that can show whether there is bleeding in the brain. This
test will show whether the stroke is ischemic or hemorrhagic.
You may also have an MRI.

Guidelines recommend that risk factors for heart disease also be
assessed after a stroke to prevent disability or death from a future heart
problem. This is because many people who have had a stroke also have
coronary artery disease.

Treatment Overview

Emergency treatment

Ischemic stroke

Measures will be taken to stabilize your vital signs,
including giving you medicines.

You may be given a clot-dissolving medicine called
tissue plasminogen activator (t-PA). This medicine can improve recovery from a stroke, especially if given as soon as possible after the
stroke happens. Doctors try to give this medicine within 3 hours after symptoms start. Some people may be helped if they are able to get this medicine within 4½ hours of their first symptoms.footnote 1

You may also receive
aspirin or
another antiplatelet medicine.

In some cases, a procedure may be done to restore blood flow. The doctor uses a thin, flexible tube (catheter) and a tiny cage to remove the blood clot that caused the stroke.

Hemorrhagic stroke

Treatment includes efforts
to control bleeding, reduce pressure in the brain, and stabilize vital signs,
especially blood pressure.

To stop the bleeding, you may be given medicine or a transfusion of parts of blood, such as plasma. These are given through an IV.

You will be
closely monitored for signs of increased pressure on the brain. These signs include
restlessness, confusion, trouble following commands, and headache. Other
measures will be taken to keep you from straining from excessive coughing,
vomiting, or lifting, or straining to pass stool or change
position.

If the bleeding is due to a ruptured
brain aneurysm, surgery to repair the aneurysm may be
done. For more information, see Surgery.

In some cases, medicines may be given to control blood
pressure, brain swelling, blood sugar levels, fever, and seizures.

If a large amount of bleeding
has occurred and symptoms are quickly getting worse, you may need surgery to
remove the blood that has built up inside the brain and to lower pressure
inside the head.

Preventing another stroke

Your treatment will also focus on
preventing another
stroke. This may include:

Reducing
high blood pressure, the most common risk factor for
stroke, by making changes to your diet and taking medicines that lower blood pressure.

Taking aspirin or another antiplatelet medicine to
prevent strokes. For more information, see Medications.

Controlling
diabetes. Your doctor will advise you to try to keep
your blood sugar levels in a target range. To do this, you may
need to take insulin or other diabetes medicine. A healthy diet and plenty of exercise will also help.

Getting a flu shot every year to
help you avoid getting sick from the
flu.

You may also need to make lifestyle changes such
as quitting smoking, eating heart-healthy foods, and being more active. For more information, see Prevention.

Rehab

Starting a
rehab program as soon as possible after a
stroke increases your chances of regaining some of the abilities you
lost.

It's not
possible to predict how much ability you will regain. The
more ability you retain immediately after a stroke, the more independent you
are likely to be when you are discharged from the hospital.

Walking: People usually show the greatest progress in
being able to walk during the first 6 weeks. Most recovery occurs within the
first 3 months. But you may continue to improve slowly over the next few
years.

Speech, balance, daily skills: Speech, balance, and skills needed for day-to-day living
return more slowly and may continue to improve for up to a
year.

Communication, judgment: About half of the people who suffer a stroke have problems
with communication, judgment, or behavior that affects their work
and personal relationships.

If your doctor wants to find out how the stroke has affected your ability to reason, concentrate, or remember, you may have neuropsychological tests.

Your
rehab will be based on the physical abilities that were lost, your
general health before the stroke, and your ability to participate.
Rehab begins with helping you resume activities of daily living, such
as eating, bathing, and dressing. For more information, see the topic
Stroke Rehabilitation.

Long-term care

If you get
worse, your loved ones may need to move you to a care facility
that can meet your needs, especially if your caregiver has his or her own
health problems that make it difficult to properly care for you.

It is common
for caregivers to neglect their own health when they are caring for a loved one
who has had a stroke. If your caregiver's health declines, the risk of injury
to you and your caregiver may increase.

Palliative care

Palliative care is a kind of care for people who have a serious illness. It's different from care to cure your illness. Its goal is to improve your quality of life—not just in your body but also in your mind and spirit.

You can have this care along with treatment to cure your illness. You can also have it if treatment to cure your illness no longer seems like a good choice.

Palliative care providers will work to help control pain or side effects. They may help you decide what treatment you want or don't want. And they can help your loved ones understand how to support you.

End-of-life care

A time may come when treatment for your illness no longer seems like a good choice. This can be because the side effects, time, and costs of treatment are greater than the promise of cure or relief. But you can still get treatment to make you as comfortable as possible during the time you have left. You and your doctor can decide when you may be ready for hospice care.

Prevention

You can help prevent a stroke if you
control risk factors and treat other medical conditions that can lead to a
stroke. You can help prevent a TIA or stroke by taking steps toward a heart-healthy lifestyle.

Know your stroke risk

Your doctor can help you know your risk. These are some of the common risk factors for stroke:

Anticoagulant medicines

You may need to take this type of medicine after a stroke if you have atrial fibrillation or another condition that makes you more likely to have another stroke. For more information, see the topic Atrial Fibrillation.

Other medicines

Surgery

When surgery is being considered after a
stroke, your age, prior overall health, and current
condition are major factors in the decision.

Surgery for ischemic stroke

If you have serious blockage in the carotid arteries in your neck, you may need a carotid endarterectomy. During this surgery, a surgeon removes plaque buildup in the carotid arteries. The benefits and risks of this surgery must be carefully weighed, because the surgery itself may cause a stroke.

Other Treatment

Carotid artery stenting (also called carotid angioplasty and stenting) is sometimes done as an alternative to surgery to prevent stroke.

In this procedure, a doctor threads a thin tube called a catheter through an artery in the groin and up to the carotid artery in your neck. The doctor then uses a tiny balloon to enlarge the narrowed portion of the artery and places a stent to keep the artery open.

Other Works Consulted

Adams RJ, et al. (2003). Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: A scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Circulation, 108(10): 1278–1290. Also available online: http://circ.ahajournals.org/content/108/10/1278.full.

Latchaw RE, et al. (2003). Guidelines and recommendations for perfusion imaging in cerebral ischemia: A scientific statement for healthcare professionals by the writing group on perfusion imaging, from the Council on Cardiovascular Radiology of the American Heart Association. Stroke, 34(4): 1084–1104. Also available online: http://stroke.ahajournals.org/content/34/4/1084.full.

Meschia JF, et al. (2014). Guidelines for the primary prevention of stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, published online October 28, 2014. DOI: 10.1161/STR.0000000000000046. Accessed October 29, 2014.

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